Review finds care at Wye Valley NHS Trust fell short of NHS standards in some areas

NHS England today (Wed) released the findings of its review into WVT. Some staff told the review that they would not want to be treated in certain wards and overspill areas covering for A&E.

The resulting report reveals areas for action as:
• Inadequate medical and nursing staff in some wards and on some sites.
• Significant scope to improve patient flow. This was adversely impacting on patient care; with inappropriate use of escalation areas (particularly the day case unit); a large number of patient moves; and problems in the tracking of patients.
• Governance arrangements - including the approach to improving patient experience which was “complex and disjointed” with key risks not being effectively addressed.
• More done to improve mortality rates. Sue Doheny, Director of Nursing for NHS England in Arden, Herefordshire and Worcestershire said:

Sue Doheny, Director of Nursing for NHS England in Arden, Herefordshire and Worcestershire said: “This was an important opportunity to independently examine the quality of patient care and treatment.  It is clear from the findings that the Trust fell short of the standards the NHS sets itself, in some clinical areas.  In certain instances, immediate action plans were implemented to raise standards of care and improve patient experience.

"It is essential that we monitor these plans closely to make sure the expected quality of care is sustained.  Longer-term action plans have been put in place to ensure enduring improvements are being made."

The review does recognise that the Trust faced “difficult challenges” given its geographic isolation and the absence of a clear strategy for providing clinically and financially sustainable services into the future.  Also recognised is the progress WVT has already made in  addressing many of issues identified.

Areas of good practice highlighted in the review include nursing staff “very committed” to providing high quality patient care often in spite of major staffing difficulties, some “excellent” individual members of staff, and the “impressive” environment, food and patient dignity at Leominster community hospital.

The review makes eight recommendations for immediate action, including the immediate safeguarding of patients in the day case unit and theatres.

A further 36 recommendations  need “urgent” attention and 31 recommendations require medium term attention..

It is of great credit to the Trust that from the time of the visit to the drafting of the report that they have already made progress in addressing many of the issues we identified. .

By category Specific findings in the report are:

Governance and leadership:
A disconnect between the quality committee, leadership team and the service unit performance meetings with an ensuing lack of clarity as to ward to board and board to ward assurance.

No clarity as to how risks and issues are appropriately escalated within the Trust, nor how the board is assured on the key risks facing the Trust.

No clinical and organisational strategy underpinning both the health economy and the Trust resulting in uncertainty and planning blight.

Concerns over the sustainability and visibility of leadership within the Trust.

Concerns over the accuracy of the reporting of key performance issues.

A cost improvement programme that  is unlikely to be delivered leading to issues over sustainability

Clinical and operational effectiveness:

Concerns about management of capacity and flow within the trust from admission to discharge
Support to clinicians poor in several areas

Concerns about the quality of care for stroke patients 
Weaknesses and inconsistencies in mortality processes

Patient experience:

No patient experience strategy and the trust is not able to articulate its priorities for patient experience

No clarity on how the board is assured on patient experience or prioritisation plan based on friends and family test  responses

Gaps in assurance in the new complaints process, and the process needs to be embedded at ward level

Scope to improve staff engagement in and ward level ownership of improving patient experience

Scope for improvement in the way the Trust acts on patient feedback

Staffing levels have a negative impact on patient experience

Serious concerns over patients’ privacy and dignity on day case unit, which would also apply to the Fred Bulmer unit when used as inpatient cover

Some staff would not want to be treated in certain wards and in escalation areas of the hospital.

Workforce and safety:

Shortfalls in the Trust’s approach to managing its workforce.

Scope to improve processes to further engrain safety or learning culture within the Trust.

Serious concerns about the safety of day case unit.

Immediate risks regarding insecure access to the theatres.

Staff  training opportunities cancelled due to operational pressures with WVT data suggesting mandatory training rates are low.

A high locum spend, and a lack of middle grade doctors.

No clear standard regarding do not attempt resuscitation (DNAR) orders, and there appeared to be a lack of engagement with patients and relatives about their use.

Staff working in the community hospitals are isolated and there is insufficient medical cover.

Staffing in the maternity unit is leading to potentially unsafe practice.

Response from Wye Valley NHS Trust:

WYE Valley NHS Trust (WVT)   is ready to “respond positively” to concerns outlined by NHS England in a review of care and treatment.

WVT chief executive Derek Smith said the report rightly highlighted areas of good practice while the “vast majority” of issues raised were already being addressed.

“We acknowledge the concerns and have already begun implementing a detailed and robust action plan which addresses these key issues in coming weeks and months,” he said.

Since the review in October WVT has completed all the “immediate” actions identified and hopes to have all urgent actions – with the exception of the stroke network - completed by the end of this month.

Amongst initiatives introduced are virtual wards, a clinical assessment unit, a revised acute admissions unit, eliminated if not restricted the use of overspill areas for A&E.
“We want to make improvements which are sustainable, lead to an improved flow of patients through our care which will ultimately give our patients a better experience. They are at the heart of the changes which we are making,” said Mr Smith.

Changes have also been made to the day surgery unit at the County Hospital following comments from the Care Quality Commission (CQC) which carried out an inspection at the same time.

The unit  is a small area of the County Hospital located near the A&E department which has been used as an overspill area when additional space is needed for  patients needing admission to the hospital.

Since the inspection, actions taken by the Trust have included:

• Limiting the number of beds in the unit
• Limiting the use of the unit
• Imposing tighter controls to improve the health, welfare and safety of patients
• Ensuring decisions to transfer patients are taken at the most appropriate level
• The adoption of processes to ensure the trust learns through its mistakes
• Making sure that staff are fully supported

Other areas of concern raised by the CQC include, staff training and support, patient information and advice, involving people in discussions about their care and treatment, and how the Trust assesses and monitors the quality of the services it provides.

“The measures we’ve already taken are addressing the issues the inspectors raised. We apologise to any patients who felt the care they received from us fell below the standard they expected and assure our patients and their carers that we are doing all we can to ensure that high standards of care are consistently available,” said Mr Smith.

WHAT IS A RAPID RESPONSE REVIEW?

The findings relating to care and treatment at Wye Valley NHS Trust are made in a Rapid Response Review (RRR) carried out by NHS England.

An RRR is a team of experienced clinicians, patients, managers and regulators from the Care Quality Commission (CQC) who visited the Trust to observe the hospital in action. 

This involved walking the wards and interviewing patients, trainees, staff and the senior executive team.  The review team then met to discuss and share their opinions before producing the report.

If a review team identify any serious concerns about the quality of care and treatment being provided to patients that they believe requires rapid action or intervention, the Trust’s Chief Executive and the relevant regulators are notified immediately.

The two day announced visit took place on  October 10-11. A further unannounced visit took place on October.

In May last year concerns were raised at regional NHS level over mortality rates at WVT – as reported by the Hereford Times.  It was agreed that an RRR should be carried out to investigate increased mortality and review the quality of care provided by WVT.

The scope of the review took in the Trust’s acute services, provided by the County Hospital, and community hospital services in Leominster, Bromyard and Ross-on-Wye.